Nasotracheal intubation under curve-tipped suction catheter guidance reduces epistaxis

Comparison of the Nasal Cavity Guidance Methods' Effects during Nasotracheal Intubation Using a Preformed Nasotracheal Tube: A Prospective Randomized Controlled Trial

Nasotracheal intubation is mainly performed to provide a safe airway during maxillofacial surgeries. Several guiding devices are suggested to facilitate nasotracheal intubation and reduce complications. We attempted to compare intubation conditions during nasotracheal intubation using a nasogastric tube and a suction catheter, which are readily available in operating rooms. In this study, 114 patients undergoing maxillofacial surgery were randomly divided into the nasogastric tube guidance group (NG group) and the suction catheter guidance group (SC group). The primary outcome was the total intubation time. Moreover, the incidence and degree of epistaxis, the position of the tube in the nasal cavity after intubation, and the number of manipulations during intubation in the nasal cavity were investigated. The insertion time from the nostril to the oral cavity and the total intubation time were significantly shorter in the SC group than in the NG group (p < 0.001). The incidence of epistaxis was lower at 35.1% in the NG group and 43.9% in the SC group than the previously reported 60-80%, but there was no statistical difference between the two groups. The use of a suction catheter aid during nasotracheal intubation can be used effectively because it shortens the intubation time and does not increase complications.

Comparison of a tube core and Magill forceps for nasotracheal intubation: a randomised controlled trial

Background

Magill forceps are frequently used to complete nasotracheal intubation (NTI). We aimed to identify a tube core that could conveniently facilitate the NTI process without using Magill forceps.

Methods

Sixty patients scheduled for oral and maxillofacial surgeries were enrolled in our study and divided into two groups (30 per group) with no differences with regard to demographic data. In the Magill forceps group (Group M), a wire-reinforced endotracheal catheter was inserted into the trachea using Magill forceps. However, in the tube core group (Group T), a tube core bent to the physiological curve of the nasal cavity and lubricated with aseptic paraffin oil was inserted into the endotracheal catheter and was then withdrawn after the endotracheal catheter was advanced through the glottis under direct vision.

Results

All NTIs were completed successfully, and Magill forceps were not used on any patient in Group T. There was a significant difference in total NTI time between the two groups (Group M, 59.7 (5.1) s vs Group T, 52.4 (3.1) s). Mild epistaxis was observed in 6 patients in Group M and 5 patients in Group T (6/30 vs 5/30, respectively). No damage to oral tissue or teeth was observed in either group.

Conclusions

We conclude that using a tube core, consisting of a disposable sterilised stylet, is a convenient choice for NTI.

Trial registration

Patient enrolment was conducted after registration in the Chinese Clinical Trial Registry (www.Chictr.org.cn, ChiCTR190002 7387). This trial was prospectively registered on 11 November 2019.

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial

Background

Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.

Methods

This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors.

Results

The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups.

Conclusions

Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI.

Trial registration

UMIN-CTR (Registration No. UMIN000037907). Registered (05/09/2019).

Nasotracheal intubation for airway management during anesthesia

Nasotracheal intubation is used as a basic method for airway management, along with orotracheal intubation under anesthesia and intensive care. It has become an effective alternative method to orotracheal intubation with increased benefits of offering better mobility and surgical field in oral and maxillofacial surgery and possibly in trauma and critically ill patients. Nasotracheal intubation is performed through a relatively narrow nasal cavity; therefore, additional precautions are needed. Accordingly, nasotracheal intubation methods have evolved over the years with accumulated clinical experience and improved instruments to facilitate safe intubation with reduced complications. Therefore, in this review article, we summarize the basic anatomy of the nasal airways to clarify the precautions, delineate the history and development of various methods and instruments, and describe the indications, contraindications, complications, and preventive methods of nasotracheal intubation.

Delayed Bleeding of Sphenopalatine Artery as a Complication in Le Fort I Osteotomy

ABSTRACT

Rates of severe complications in orthognathic surgery are low, but when they occur they can be fatal. This article reports a case of laceration of the junction of the posterior lateral nasal artery and the sphenopalatine artery, resulting in severe delayed bleeding. Patient undergoes a multiple segment Le Fort I osteotomy with no intraoperative or immediate postoperative complications. On the fourth postoperative day, he presents with epistaxis and intractable postnasal discharge, is admitted to emergency with signs of shock, and bleeding is detected endoscopically originating from the right sphenopalatine artery, which is treated with diathermocoagulation. The advantage of endoscopy in difficult areas is that bleeding complications can be solved with low morbidity.

Evaluation of Nasopharyngeal Airway to Facilitate Nasotracheal Intubation

Background and Aims:

Nasotracheal intubation is the most common method of airway management in oral and maxillofacial surgery patients. However, many times, it is associated with bleeding resulting from trauma to nasopharyngeal mucosa. We conducted this study to determine the effectiveness of nasopharyngeal airway (NPA) to easily facilitate the nasopharyngeal insertion and to reduce the trauma during nasotracheal intubation.

Methods:

A total of 120 patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly divided into two groups of 60 each, after preparation with xylometazoline drops intranasally, lubrication with lignocaine jelly, and thermosoftening of the tip of the endotracheal tube (ETT). In group NPA, dilatation of the nasal cavity was done with NPA before nasotracheal intubation and in Group C, nasotracheal intubation was done without dilatation of the nasal cavity. The smoothness of insertion of ETT was graded on a 4‑point rating scale. Assessment of bleeding into nasopharynx was confirmed during laryngoscopy and was also graded with 4‑point scale.

Results:

In the NPA group, all the 60 (100%) patients had smooth or relatively smooth (Grade 0 or 1) insertion compared to 51 (85%) patients in the control group (P < 0.0001). Eighteen (30%) patients had mild (Grade 1) bleeding and one (1.67%) patient had moderate bleeding (Grade 2) in the control group, whereas only four (6.67%) patients in the NPA group had mild (Grade 1) bleeding (P = 0.0005).

Conclusion:

Dilatation of nasal cavity with NPA significantly eases the insertion of ETT into the nasopharynx and also significantly decreases the incidence and severity of trauma and bleeding during nasotracheal intubation.

Does a Nasal Airway Facilitate Nasotracheal Intubation or Not? A Prospective, Randomized, and Controlled Study

PURPOSE

Nasotracheal intubation (NTI) is generally preferred for maxillofacial surgery to provide a more suitable and wide surgery area for the surgeons. The purpose of the study was to evaluate whether using a nasal airway just before the NTI may facilitate NTI or not.

METHODS

This prospective, randomized, and controlled study was performed on patients who were admitted to our hospital for maxillofacial surgery. In group 1, a nasal airway was used just before the NTI during mask ventilation, and patients in the group were ventilated without nasal airway. Airway group was the primary predictor of the study. The NTI duration was the primary outcome variable, and the number of attempts was the secondary outcome variable. Difficulty of ventilation and complications were the other variables that were recorded.

RESULTS

A total of 70 patients were included in the study and divided into 2 groups. There was no statistically significant relationship between the duration of NTI and other variables, but the significance value for sternomental distance, ventilation difficulty, and epistaxis was P < .10. The NTI duration (the primary outcome variable) and the number of attempts (the secondary outcome variable) are statistically lower in the nasal airway group (group 1) than the control group (group 2). Ventilation difficulty was significantly higher in group 2 when compared with group 1 (P = .04). The model and regression coefficients for both variables are statistically significant in terms of duration of NTI and number of attempt values that they were lower in nasal airway group than the control group. There were no statistically significant differences between the groups in terms of complications (P < .05).

CONCLUSIONS

The present study has shown that inserting a nasal airway into the nostril just before the NTI may facilitate the intubation process by preparing the nasal passage.

Comparison of disinfection effect between benzalkonium chloride and povidone iodine in nasotracheal intubation: a randomized trial

Background

Nasotracheal intubation can potentially result in microbial contamination from the upper respiratory tract to the lower respiratory tracts. However, an ideal nasotracheal disinfection method is yet to be determined. Therefore, we compared the disinfection effects between benzalkonium chloride and povidone iodine in nasotracheal intubation.

Methods

Overall, this study enrolled 53 patients aged 20–70 years who were classified into classes 1 and 2 as per American Society of Anesthesiologists-physical status and were scheduled to undergo general anesthesia with NTI. Patients who did not give consent (n = 2) and who has an allergy for BZK or PVI were excluded from the study. The patients were randomly divided into two groups on the basis of the disinfection method: BZK (n = 26, one patient was discontinued intervention) and PVI (n = 25). 50 patients were assessed finally.

The subjects’ nasal cavities were swabbed both before (A) and after disinfection (B), and the internal surface of the endotracheal tube was swabbed after extubation (C). The swabs were cultured on Brain heart infusion agar and Mannitol salt agar. The number of bacteria per swab was determined and the rates of change in bacterial count (B/A, C/B) were calculated. The growth inhibitory activity of the disinfectants on Staphylococcus aureus were also investigated in vitro.

Results

Although the initial disinfection effects (B/A) were inferior for benzalkonium chloride compared with those for povidone iodine, the effects were sustained for benzalkonium chloride (C/B). In the in vitro growth inhibitory assay against S. aureus, benzalkonium chloride showed higher inhibitory activity than povidone iodine.

Conclusion

Although both disinfectants were inactivated or diffused/diluted over time, benzalkonium chloride maintained the threshold concentration and displayed antimicrobial effects longer than povidone iodine; therefore, benzalkonium chloride appeared to show a better sustained effect. Benzalkonium chloride can be used for creating a hygienic nasotracheal intubation environment with sustained sterilizing effects.

Trial registration

UMIN-CTR (Registration No. UMIN000029645). Registered 21 Oct 2017.

A comparison between the Disposcope endoscope and fibreoptic bronchoscope for nasotracheal intubation: a randomized controlled trial

Background

Nasotracheal intubation (NTI) is frequently performed for oral and maxillofacial surgeries. This study evaluated whether NTI is easier when guided by Disposcope endoscopy or fibreoptic bronchoscopy.

Methods

Sixty patients (30 per group) requiring NTI were randomly assigned to undergo fibreoptic bronchoscopy-guided (fibreoptic group) or Disposcope endoscope-guided (Disposcope group) NTI. The NTI time, which was defined as the time from when the fibreoptic bronchoscope or aseptic suction catheter was inserted into the nasal cavity to the time at which the tracheal tube was correctly inserted through the glottis, was recorded. Epistaxis was evaluated by direct laryngoscopy five minutes after completing NTI and was scored as one of four grades according to the following modified criteria: no epistaxis, mild epistaxis, moderate epistaxis, and severe epistaxis.

Results

The time to complete NTI was significantly longer in the fibreoptic group than in the Disposcope group (38.4 s vs 24.1 s; mean difference, 14.2 s; 95% confidence interval (CI), 10.4 to 18.1). Mild epistaxis was observed in 8 patients in the fibreoptic group and in 7 patients in the Disposcope group (26.7% vs 23.3%, respectively; relative risk, 1.2; 95% CI, 0.4 to 3.9), though no moderate or severe epistaxis occurred in either group. Furthermore, no obvious nasal pain was reported by any of the patients at any time point after extubation (P = 0.74).

Conclusion

NTI can be completed successfully using either fibreoptic bronchoscopy or Disposcope endoscope as a guide without any severe complications. However, compared to fibreoptic bronchoscopy, Disposcope endoscope requires less execution time (the NTI time).

Trial registration

This clinical research was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPR-17011462, date of registration, May 2017).

North Polar Tube Reduces the Risk of Epistaxis during Nasotracheal Intubation: A prospective, Randomized Clinical Trial

Objective

In this study, a north polar tube (Portex^® North Polar tube [Ivory PVC Portex tube; Smiths Medical International, Hythe, United Kingdom]) (NPT) and spiral tube (ST) were compared for their ability to provide a nasal airway in patients during maxillofacial surgery.

Methods

Patients who were aged 18 to 65 years with American Society of Anaesthesiologists score 1 to 2 and Mallampati score 1 to 2 were included in the study. The anesthesia technique was standardized in all patients. Patients were divided into 2 groups randomly: the NPT (n = 35) and ST groups (n = 35). Anesthesia was administered with 1% to 2% sevoflurane and a mixture of 50% oxygen + 50% air in both groups. The mean arterial pressure and heart rate values of preinduction; preintubation; and the first, second, third, and fifth minutes of intubation were recorded. Epistaxis, intraoral bleeding, cuff burst, use of Magill pens, duration of intubation, intubation difficulty, laryngeal compression, head position change, and glottic grade were evaluated.

Results

There were no significant differences between groups in terms of demographic data (gender, age, height, weight, body mass index, American Society of Anaesthesiologists score, and Mallampati score). Macintosh laryngoscopes were used during intubation in all patients. There was no significant difference between groups in terms of intubation difficulty, duration of intubation, use of Magill pens, and determination of the glottic grade (P > 0.05). Epistaxis was significantly lower in the NPT group than in the ST group (P = 0.012). Intraoral bleeding was significantly higher in the ST group than in the NPT group (P = 0.001). During intubation, laryngeal compression (Sellick maneuver) and head position changes were significantly lower in the NPT group than in the ST group (P = 0.003 and P < 0.001, respectively). There were no significant differences in mean arterial pressure and heart rate between the 2 groups.

Conclusions

We conclude that the NPT was associated with less epistaxis and manipulations such as laryngeal compression and head position changes when compared with the ST during nasotracheal intubation. The velvet-soft polyvinyl chloride material of the NPT appears to be responsible for this advantage.

Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Background

Nasotracheal intubation is a blind procedure that may lead to complications; therefore, several tests were introduced to assess a suitable nostril for nasotracheal intubation. However, the value of simple tests in clinical practice was insufficient to evaluate.

Method

A diagnostic prospective study was conducted in 42 patients, ASA classes I–III, undergoing surgery requiring nasotracheal intubation for general anesthesia. Two simple methods for assessing the patency of nostrils were investigated. Firstly, the occlusion test was evaluated by asking for the patient's own assessment of nasal airflow during occlusion of each contralateral nostril while in a sitting posture. Secondly, patients breathed onto a spatula held 1 cm below the nostrils while in a sitting posture. All patients were assessed using these two simple tests. Nasal endoscopic examination of each patient was used as a gold standard.

Results

The diagnostic value of the occlusion test (sensitivity of 91.7%, specificity of 61.1%, PPV of 75.9%, NPV of 84.6%, LR+ of 2.36, and LR− of 0.14) seemed better than that of the spatula test (sensitivity of 95.8%, specificity of 25.0%, PPV of 63.0%, NPV of 81.8%, LR+ of 1.28, and LR− of 0.17). When both tests were combined in series, the diagnostic value increased (sensitivity of 87.9%, specificity of 70.8%, PPV of 80.1%, NPV of 81.4%, LR+ of 3.01, and LR− of 0.17).

Conclusion and Recommendations

The simple occlusion test is more useful than the spatula test. However, combining the results from both tests in series helped to improve the diagnostic value for selecting a suitable nostril for nasotracheal intubation.

Retropharyngeal Dissection by Parker Flex-Tip Nasal Endotracheal Tube

Possible complications of nasotracheal intubation include injury to the nasal or pharyngeal mucosa. Dissection of the retropharyngeal tissue by the endotracheal tube is one of the rarer of the more severe complications. Previous studies have indicated that the Parker Flex-Tip (PFT) tracheal tube (Parker Medical, Highlands Ranch, Colo) reduces the incidence of mucosal injury. We experienced a case involving inadvertent retropharyngeal placement of a PFT tube in a 29-year-old patient during nasotracheal intubation under general anesthesia for elective dental treatment. Despite thermosoftening the PFT tube, expanding the nasal meatus, and ensuring gentle maneuvering, the tube intruded into the left retropharyngeal mucosa. However, the injury was not severe, and the only required treatment was the administration of antibiotics and corticosteroids. Even when a PFT tube is utilized, pharyngeal dissection is possible. When resistance is felt during passing of the PFT tube through the nasopharynx, an alternative method to overcome this resistance should be utilized.

Learning fiberoptic intubation for awake nasotracheal intubation

Background

Fiberoptic nasotracheal intubation (FNI) is performed if it is difficult to open the mouth or if intubation using laryngoscope is expected to be difficult. However, training is necessary because intubation performed by inexperienced operators leads to complications.

Methods

Every resident performed intubation in 40 patients. Success of FNI was evaluated as the time of FNI. First intubation time was restricted to 2 min 30 s. If the second attempt was unsuccessful, it was considered a failed case, and a specialist performed nasotracheal intubation. If the general method of intubation was expected to be difficult, awake intubation was performed. The degree of nasal bleeding during intubation was also evaluated.

Results

The mean age of the operators (11 men, 7 women) was 27.8 years. FNI was performed in a total of 716 patients. The success rate was 88.3% for the first attempt and 94.6% for the second attempt. The failure rate of intubation in anesthetized patients was 4.9%, and 13.6% in awake patients. When intubation was performed in anesthetized patients, the failure rate from the first to fifth trial was 9.6%, which decreased to 0.7% when the number of trials increased to > 30 times. In terms of awake intubation, there was no failed attempt when the resident had performed the FNI > 30 times. The number of FNIs performed and nasal bleeding were important factors influencing the failure rate.

Conclusion

The success rate of FNI increased as the number of FNI performed by residents increased despite the nasal bleeding.

A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation

Background

Various techniques have been introduced to decrease complications during nasotracheal intubation. A common practice is to use nasal packing with a cotton stick and 0.01% epinephrine jelly. However, this procedure can be painful to patients and can damage the nasal mucosa. Xylometazoline spray can induce effective vasoconstriction of the nasal mucosa without direct nasal trauma. In this study, we aimed to compare the efficacy of these two methods.

Methods

Patients were randomly allocated into two groups (n = 40 each): xylometazoline spray group or epinephrine packing group. After the induction of general anesthesia, patients allocated to the xylometazoline spray group were treated with xylometazoline spray to induce nasal cavity mucosa vasoconstriction, and the epinephrine packing group was treated with nasal packing with two cotton sticks and 0.01% epinephrine jelly. The number of attempts to insert the endotracheal tube into the nasopharynx, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. An anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5 min after intubation and postoperative complications.

Results

No significant intergroup difference was observed in navigability (P = 0.465). The xylometazoline spray group showed significantly less epistaxis during intubation (P = 0.02). However, no differences were observed in epistaxis 5 min after intubation or postoperative epistaxis (P = 0.201). No inter-group differences were observed in complications related to nasal intubation and nasal pain.

Conclusion

Xylometazoline spray is a good alternative to nasal packing for nasal preparation before nasotracheal intubation.

The Potential Significance of Concha Bullosa During Nasotracheal Intubation

The authors experienced a case of severe epistaxis caused by accidental partial middle turbinectomy during nasotracheal intubation, which the patient had bilateral concha bullosa narrowing the nasal airway. Although anesthesiologist checked nasal airway through subjective symptoms and the size of both nostrils, they tend to overlook common anatomic variation, concha bullosa, and can injure turbinate structures. Therefore, preoperative computed tomography images should be carefully evaluated for the possibility of concha bullosa, which narrows nasal airway and induces the traumatic injury or epistaxis during nasotracheal intubation.

Validity of rhinometry in measuring nasal patency for nasotracheal intubtion

PURPOSE

Numerous techniques have been used to reduce epistaxis during nasotracheal intubation. Rhinometry can assess nasal patency in preoperative conditions. However, the possible role of rhinometry in routine nasotracheal intubation has not been studied.

METHODS

One hundred and one patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. We examined whether symmetry or any asymmetry in bilateral airflow patterns by condensation of the expiration, assessed by preoperative rhinometry on seated position, increased the incidence of epistaxis and the need for a nasogastric catheter to guide the endotracheal tube into the oropharynx. We also compared the incidence of changing the site of nasal intubation between the assessment by rhinometry and by cone-beam computed tomography analysis of nasal airspace in the inferior meatus.

RESULTS

Patients with any asymmetry in bilateral airflow patterns were 18 % (n = 18), the remaining 82 % (n = 83) had symmetric bilateral nasal cavities. Patients with any asymmetry were more likely to need a guiding nasogastric catheter than patients with symmetry (22 vs. 3.6 %, p = 0.018). The incidence of epistaxis was higher in patients with any asymmetry (39 %) than those with symmetry (16 %), but there was no significant difference between groups (p = 0.055). The site of intubation was changed more frequently based on cone-beam computed tomography analysis than by rhinometry (38 vs. 11 %, p = 0.043).

CONCLUSION

Preoperative rhinometry may be a valuable objective tool to assess nasal patency for nasotracheal intubation in patients who undergo dental and maxillofacial surgery.

Inspection of the nasopharynx prior to fiberoptic-guided nasotracheal intubation reduces the risk epistaxis

BACKGROUND

Various complications may occur during nasotracheal intubation. This may include epistaxis and damage to the nasopharyngeal airway. We tested the hypothesis that the use of fiberoptic bronchoscopy (FOB)-guided intubation is superior to endotracheal tube (ETT) obturated with an inflated esophageal stethoscope.

METHODS

Patients were randomly assigned to 1 of 2 groups (n=22 each): either an FOB-guided intubation group or ETT obturated with an inflated esophageal stethoscope group. After the induction of general anesthesia, patients in the FOB group received an FOB inspection through the nostril without advancement of ETT. Then, after confirming the placement of the bronchoscope tip in the trachea, the lubricated ETT was advanced via the nostril to the trachea along the bronchoscope. In the obturated ETT insertion group, the proximal opening of the ETT was blunted with an inflated esophageal stethoscope. The ETT was inserted into the selected nostril and advanced blindly into the posterior oropharynx. Then, the esophageal stethoscope was removed and tracheal intubation was performed with the bronchoscope. The number of attempts for successful tracheal intubation, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. Another anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5minutes after the intubation and postoperative complications.

RESULTS

The FOB group had significantly less epistaxis during bronchoscopy, better navigability, and fewer intubation attempts and redirections.

CONCLUSION

Fiberoptic-guided nasotracheal intubation was associated with less epistaxis. It also showed better navigability and less redirection rate. Therefore, FOB as an intubation guide is superior to ETT with an inflated esophageal stethoscope when intubating a patient via the nasotracheal route.

Repeated General Anesthesia in a Patient With Noonan Syndrome

Noonan syndrome (NS) is an autosomal dominant disorder characterized by facial anomalies, short stature, chest deformity, congenital heart diseases, and other comorbidities. The challenges faced during anesthetic management of patients with NS could be due to congenital heart diseases, hemostatic disorders, and airway anomalies. Here we describe dental treatment under general anesthesia performed for a 28-year-old man with NS. He had characteristic features of NS along with mild pulmonary valve stenosis. Dental treatment under general anesthesia was performed successfully on 13 occasions with nasotracheal intubation under curve-tipped suction catheter guidance or insertion of a reinforced laryngeal mask airway. This case suggests that for patients with NS, who might present several challenges, dental anesthesiologists should consider the extent of the patient's disorders to enable them to perform dental treatment safely under general anesthesia.

A complication of nasotracheal intubation after mandibular subcondylar fracture

Among the potential risks of nasotracheal intubation are nasal bleeding, sinusitis, bacteremia, accidental turbinectomy, and some other structural damages. Retropharyngeal dissection is reported as a very rare complication of nasotracheal intubation, mostly encountered in elective surgery patients. A case with traumatic subcondylar fracture of the mandible is presented here, which is suspected to be the cause of the nasopharyngeal dissection that was observed during attempted nasotracheal intubation.

Reducing nasopharyngeal trauma: the urethral catheter-assisted nasotracheal intubation technique

Nasal intubation is an advantageous approach for dental procedures performed in the hospital, ambulatory surgery center, or dental office, when possible. Although many who provide anesthesia services are familiar and comfortable with nasal intubation techniques, some are reluctant and uncomfortable because of lack of experience or fear of nasopharyngeal bleeding and trauma. It has been observed from experiences in various settings that many approaches may be adapted to the technique of achieving nasal intubation. The technique that is described in this paper suggests a minimally invasive approach that introduces the nasoendotracheal tube through the nasopharyngeal pathway to the oropharynx in an expedient manner while preserving the nasopharyngeal structures, thus lessening nasal bleeding and trauma to soft tissues. The technique uses a common urethral catheter and can be incorporated along with current intubation armamentaria. As with all techniques, some limitations to the approach have been identified and are described in this paper. Cases with limited mouth opening, neck injury, and difficult airways may necessitate alternative methods. However, the short learning curve along with the many benefits of this technique offers the anesthesia professional additional options for excellent patient care.

Parker flex-tip and standard-tip endotracheal tubes: a comparison during nasotracheal intubation

The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.

Retropharyngeal dissection during nasotracheal intubation: a rare complication and its management

Nasotracheal intubation carries potential risks, including nasal bleeding and other structural damage. We report a retropharyngeal dissection (or a false passage in the nasopharyngeal mucosa) during attempted nasotracheal intubation of a 54-year-old woman undergoing lower jaw reconstruction.

Case report: nasotracheal intubation--look before leaping to assess the laryngeal view

PURPOSE

To describe an airway management plan, including oral to nasal endotracheal tube exchange, when nasal intubation is required in the unanticipated difficult airway.

CLINICAL FEATURES

A nasal intubation was required for a patient undergoing oropharyngeal surgery. Following loss of consciousness and paralysis, a Cormack-Lehane class 3 view was obtained, and pressure over the thyroid cartilage failed to reveal the vocal cords. An Eschmann bougie was inserted into the oropharynx and blindly entered the trachea. An orotracheal tube was advanced into the trachea over the bougie, and the patient was ventilated with 100% O2 following the bougie's removal. An endotracheal tube was then guided through the right nostril into the hypopharynx. An Eschmann bougie was inserted into the nasal tube, and advanced towards the glottic opening under laryngoscopic view. Digital pressure applied to the oral tube at the base of the tongue brought the vocal cords into view. The oral endotracheal cuff was deflated, and the bougie (inserted into the nasal tube) was advanced into the trachea alongside the orotracheal tube. The orotracheal tube was withdrawn, and the nasal tube was advanced into the trachea over the bougie. The patient's O2 saturation and end-tidal CO2 concentration remained at 99-100% and 30-33 mmHg, respectively, during these maneuvers, which required only a few minutes to perform.

CONCLUSION

When nasotracheal intubation is required, a plan of airway management is required to safely secure the airway. We emphasize the importance of direct laryngoscopy prior to insertion of an endotracheal tube through the nose, and describe a strategy for oral to nasal tracheal tube exchange.